The Opioid Crisis and the Need for Compassion in Pain Management

The tragedy of the opioid crisis in the United States has been well documented. Between 1999 and 2014, opioid sales and opioid-related deaths increased nearly fourfold.¹ Also, between 1999 and 2015, more than 183 000 people died in the United States of overdoses related to prescription opioids.¹ In 2012, health care providers in the United States wrote 259 million prescriptions for opioid pain medication, one for every adult in the country.² Prescriptions for these powerful opioids were encouraged and aggressively marketed to physicians and patients by certain pharmaceutical companies, often without disclosing the highly addictive nature of their products.³ The nation is now confronting the public health consequences of opioid abuse, but we must not forget that many patients desperately need effective pain management.

As the trail of addiction and death spread across the United States, various laws and regulations were enacted to combat opioid abuse. Most notably, prescription drug monitoring programs were established in nearly every state to track opioid prescriptions in an attempt to prevent patients from engaging in physician shopping for multiple prescriptions and to prevent physicians from writing excessive numbers of opioid prescriptions.

Other measures designed to prevent opioid abuse include state laws that place limits on the number of opioid pills that can be dispensed from a single prescription, such as a seven-day supply. Private agreements between physicians and patients, including opioid contracts, also have proliferated. Among other things, these agreements typically provide that patients seeking refills must do so during regular office hours, and patients are subject to random pill counts and drug testing to ensure that they are actually taking the medicine and not diverting it.

REFUSAL TO PRESCRIBE OPIOIDS

Prescription drug monitoring programs are associated with significant reductions in opioid prescribing by physicians,⁴ although other explanations account for the sharp drop in opioid prescribing in the last few years.⁵ Many physicians who previously prescribed opioids now have reduced or discontinued such prescriptions, even for established patients with chronic pain. In some cases, the change in policy was adopted literally overnight. Many patients seeking refills were simply told that they needed to stop taking opioids. With no alternatives for pain control, long waiting lists for substance abuse treatment programs, and the physical and mental pressure of unremitting pain, many patients turned to illicit drugs, especially heroin. The result has been greater addiction, more deaths from overdoses, and an increase in cases of HIV/AIDS and hepatitis from contaminated syringes.

The two main arguments in support of new “no opioid” policies are that (1) these policies help patients because literature indicates that long-term opioid treatment of chronic, non–cancer-related pain has unproven benefits and serious risks, and (2) some physicians do not want to care for patients with addictions because they lack training in addiction medicine and lack experience in tapering patients from higher doses of opioids. These arguments are unconvincing. As to the first argument, even though opioids may not improve the long-term clinical course for many patients, potent analgesics can provide relief during an acute episode. As to the second argument, patients with substance use problems that most likely began by receiving lawful prescriptions for opioids to control pain should not be cast aside by their physicians. The opioid dependency of patients can be improved with proper management, but it will become life threatening if vulnerable patients are left to their own devices for pain relief. In a significant percentage of cases, changed prescribing policies by physicians merely reflect a new negative view of opioids and the perception of professional risks in prescribing them.⁶

One of the saddest parts of the evolving saga of opioid abuse is that some patients with excruciating pain from debilitating conditions now are being told that they must rely on wholly ineffective over-the-counter analgesics. Opioid prescribing in many medical practices has been limited to postoperative, cancer, and terminally ill patients. For individuals who experience periodic flare-ups of severe pain from chronic conditions, merely having an emergency supply of pain medication has great psychological value in permitting them to live their lives without constant fear of an attack and no immediate way of obtaining relief.

In theory, a medical malpractice case or disciplinary action by a state medical board could result from either overprescribing opioids or failing to adequately treat the pain of patients. Even federal criminal liability is possible under the Controlled Substances Act. The legal morass of opioid regulation helps to explain some of the disquietude of physicians as well as the need to develop and implement appropriate guidelines for pain control.

THE PENDULUM HAS SWUNG BACK TOO FAR

Recently, “the movement to virtually eliminate opioids as an option for chronic pain refractory to other treatments is an overreaction.”⁷ Physicians should carefully reconsider before they decline to treat their patients’ pain because they think it might create professional problems. Such conduct lacks compassion for suffering patients, fails to meet a reasonable standard of care, and contravenes foundational principles of medical ethics.

Many actors can play a role in addressing the undertreatment of pain, including the following:

1. medical schools and continuing medical education providers;

2. licensing and accrediting bodies, such as state medical boards and the Joint Commission;

3. the Centers for Medicare and Medicaid Services and other public and private payers;

4. health care institutions;

5. medical professional societies; and

6. patient advocacy groups.

These entities should increase their educational programs in pain management, condition financial and other benefits on enlightened pain management policies, increase research on pain control, and commit to the adoption of measures that provide appropriate pain management and prevent opioid abuse. In particular, physicians should not remove themselves from involvement in the opioid crisis. As society searches for effective and fair measures to deal with the overall problem of substance abuse, physicians should apply their expertise to care for the needs of all of their patients.

GOING FORWARD

Professional standards for treating pain should be evidence-based and responsive to patients’ needs. They should be implemented carefully by trained professionals in a way that involves reasonable oversight of prescribing practices.³ Pain management regulatory policies should not inordinately burden physicians or patients, and they should not presume that all physicians are reckless prescribers or that all patients are deceitful drug seekers. Nevertheless, policies should recognize that unlawful activities frequently occur when opioids are prescribed and dispensed, and health care providers and institutions should take reasonable steps to prevent such conduct.

Added to the public health crisis of opioid addiction is a growing crisis of inadequate treatment of pain. Desperately ailing patients who legitimately need medical relief from serious pain should not be the latest unintended victims of societal opioid abuse.